Abstract
Mr. Johnson is a 62-year-old man with no prior past medical history who is admitted to the intensive care unit (ICU) after suffering a large cryptogenic stroke in the past 24 hours, with the majority of his left middle cerebral artery (MCA) now infarcted on neuroimaging. Despite his being globally aphasic with a right hemiparesis, a gaze deviation to the left, and a right-sided hemianopsia, his eyes initially open to voice easily, he has symmetric pupils, and he is protecting his airway. Several hours later in the ICU, the nurse notes that he still has symmetric pupils, but his eyes now require noxious stimulation to open, and he seems to be snoring. His serum sodium is 145 mEq/L; a repeat computed tomography scan of the head (Figure 11.1) shows that he has developed an interval increase in cerebral edema and now has a few millimeters of left-to-right midline shift. His family “doesn’t want him to die” and is very hopeful that he might improve in the future, saying that he is a very active 62-year-old. You walk into a meeting with the family after ordering mannitol and being told by the nurse that someone on the team had already mentioned the possibility of decompressive craniectomy to them.
Mr. Johnson is a 62-year-old man with no prior past medical history who is admitted to the intensive care unit (ICU) after suffering a large cryptogenic stroke in the past 24 hours, with the majority of his left middle cerebral artery (MCA) now infarcted on neuroimaging. Despite his being globally aphasic with a right hemiparesis, a gaze deviation to the left, and a right-sided hemianopsia, his eyes initially open to voice easily, he has symmetric pupils, and he is protecting his airway. Several hours later in the ICU, the nurse notes that he still has symmetric pupils, but his eyes now require noxious stimulation to open, and he seems to be snoring. His serum sodium is 145 mEq/L; a repeat computed tomography scan of the head (Figure 11.1) shows that he has developed an interval increase in cerebral edema and now has a few millimeters of left-to-right midline shift. His family “doesn’t want him to die” and is very hopeful that he might improve in the future, saying that he is a very active 62-year-old. You walk into a meeting with the family after ordering mannitol and being told by the nurse that someone on the team had already mentioned the possibility of decompressive craniectomy to them.
Figure 11.1 Malignant left MCA infarction on a computed tomography scan.
Patients with occlusions of the MCA or internal carotid artery and large hemispheric strokes are typically admitted to the ICU for neurologic monitoring. The phrase “malignant MCA syndrome” was first coined in 1996 by Hacke to describe a syndrome of severe hemiparesis and sensory loss, horizontal gaze deviation, and global aphasia (for a dominant hemisphere stroke) that progresses to declining mental and possibly respiratory status over a few days owing to cerebral edema.1–4 High rates of mortality (approaching 80%) without decompressive craniectomy, as precipitated by compression of the brainstem often occurring within 2 to 5 days of the infarction, are well-documented.1, 2, 5 However, determining with neurosurgical colleagues to offer a decompressive craniectomy for an ICU patient with a large hemispheric stroke is often a challenging shared decision for the patient’s family, because of the concern of prolonging what may turn out to be a poor quality of life (QoL) for the patient. In this Chapter, we discuss previously completed trials of decompressive craniectomy and consider factors that may inform shared decision-making in these crucial moments.
11.1 Decompression and Outcomes
Several studies and multiple meta-analyses have been completed to understand the role of decompressive craniectomy in the treatment of malignant MCA stroke. These studies all use the modified Rankin Scale (mRS) as a means of quantifying long-term disability, as described in Table 11.1. This ordinal scale starts at 0, indicating no symptoms, and runs to 6, indicating death, with the difference between scores of 3 and 4 being the ability to ambulate and attend to one’s own bodily needs without assistance.6 Scores of 3 and 4 in particular present a challenge when applied to real-life shared decision-making due to the wide array of disability they convey and degree to which this affects a patient’s sense of QoL. This challenge has led to an active debate and discussion of how best to judge the impact of intervention in malignant strokes.
Table 11.1. Modified Ranking Scale scoring description
11.2 Patients Age 18–60 Years Old
In 2006, enrollment in the Decompressive Craniectomy in Malignant Middle Cerebral Artery Infarcts (DECIMAL)7 and Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY)8 studies were aborted prematurely to combine data along with that from Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial (HAMLET)9, 10 as a meta-analysis, which is now the commonly used dataset cited when discussing outcomes for decompressive craniectomy.11 Owing to differences in the original eligibility requirements for each study, this meta-analysis included only those subjects between the ages of 18 and 60 with neuroimaging demonstrating infarction in at least 50% of the MCA territory or a volume of greater than 145 mL. Together, 93 patients who had been randomized within 45 hours of symptom onset and intervention completed within 48 hours were included in the meta-analysis.11
The primary outcome in the analysis was mRS measured at 12 months and dichotomized to favorable outcome (mRS of 0–4) versus unfavorable (mRS of 5–6), with the recognition that the goal of surgery should be to decrease mortality without an increase in severely disabled survivors. Pooled data demonstrated that decompressive craniectomy decreased rates of death from 71% to 22% and was associated with an absolute risk reduction of 51.2% at 1 year (Figure 11.2).11 As a secondary aim, results were also dichotomized with favorable outcome being defined as a mRS of 0 to 3 and revealed a significant difference between those in the treatment versus conservative arm, with an absolute risk reduction of 22.7%. Survival with an mRS of 0–3 nearly doubled at 12 months for those in the surgical arm, although ultimately survival with a mRS of 4 increased by nearly 10 times. Before the results of this pooled analysis, there was concern that, although decompressive craniectomy could improve rates of survival, the majority of these survivors were left with an mRS of 5. This was not seen in these data, because the rate of survival with an mRS of 5 was equivocal between the study groups.
Figure 11.2 Pooled analysis of the DECIMAL, DESTINY, and HAMLET (1-year patient outcomes) studies.
11.3 Patients Older Than Age 60
Discussion of an age limit for surgical intervention in malignant infarctions is controversial, but frequently discussed among neurologists, neurosurgeons, and intensivists.12 Although the original trials of decompression focused on younger patients, the DESTINY-2 study was conducted from 2009 to 2013 to assess outcomes in patients older than 60 undergoing decompressive craniectomy.13
Enrollment was stopped after 82 patients had reached the 6-month primary outcome, defined as favorable with an mRS of 0–4 versus unfavorable with an mRS of 5 or 6. The results of the primary outcome favored the surgical intervention group with an odds ratio of 2.91 (95% confidence interval, 1.06–7.49; p = .04), although of note only 7% of patients in the intervention arm survived with a mRS of 3 or less versus 3% in the conservative arm (Figure 11.3).13 Survival with severe disability was found in 28% of the intervention group versus only 13% of the conservative treatment arm, although death was documented much less frequently, namely, 33% compared with 70%.
Related posts:
Chapter 2 – How Much Does the Family Want to Be Involved in Decision-Making?
Chapter 4 – Communication Skills for Critical Care Family Meetings
Chapter 5 – The Do-Not-Resuscitate Order
Chapter 6 – The Do-Not-Intubate Order
Chapter 19 – Measuring and Evaluating Shared Decision-Making in the Intensive Care Unit
Chapter 20 – Brain Death Discussions
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